Deck 2 Module 30 Flashcards
A client says that even though a diagnosis of hypertension is disappointing, with medication and lifestyle changes, it can be controlled and the client will become a better person. Based on this data, which aspect of spirituality is the client demonstrating? A) Connecting B) Meaning C) Value D) Becoming
D) Becoming
Rationale:
There are five aspects of spirituality. Becoming involves reflection and allowing life to unfold to know who one is. This is what the client is demonstrating. Value is having cherished beliefs and standards. Meaning is having purpose. Connecting is relating to others or to an Ultimate Other.
The nurse is providing care to a client diagnosed with type 2 diabetes mellitus. The client wishes to take Communion but must fast for one hour prior to receiving it. Which action by the nurse is most appropriate?
A) Contact the healthcare provider to suggest an alternative form of nutrition because the client is refusing to eat or drink.
B) Provide the client with breakfast and morning medication and encourage the client to eat and take Communion some other time.
C) Find out when the hospital clergy will be distributing Communion and adjust the client’s medications and breakfast accordingly.
D) Suggest that because the client is hospitalized, eating and drinking will not affect the Communion.
C) Find out when the hospital clergy will be distributing Communion and adjust the client’s medications and breakfast accordingly.
Rationale:
To support the client’s spiritual needs, the nurse should find out when Communion will be distributed and adjust the medications and breakfast accordingly. The nurse should not suggest that eating and drinking will not affect Communion. The nurse should not ignore the client’s needs by providing medication and breakfast. The nurse should also not contact the healthcare provider to suggest alternative forms of nutrition, because the client is not refusing to eat or drink but wants to delay eating and drinking until after Communion.
While assessing a client’s spiritual needs, the nurse asks, "What spiritual beliefs are important to you?" This question represents which step of the FICA assessment model? A) Community B) Address C) Implication D) Faith
D) Faith
Rationale:
Within the FICA assessment model for spirituality, faith is assessed by asking the question “What spiritual beliefs are important to you?” Implication is assessed by asking the client, “How is your faith affecting the way you cope?” Community is assessed by asking, “Is there is a community of like-minded believers with which you routinely meet?” Address is assessed by asking the client, “How can the healthcare team support your spiritual needs?”
When providing nursing care the client states, “I drink a small glass of warm water mixed with the juice of one lemon every morning because it helps to heal my body.” Which action by the nurse is appropriate when providing care to this client?
A) Tell the client that cold water is better metabolized by the body.
B) Instruct the client that lemon juice is really a dose of vitamin C that helps with healing.
C) Provide the warm water and juice of a lemon.
D) Suggest the client delay the water and lemon until after morning medications.
C) Provide the warm water and juice of a lemon.
Rationale:
To support the client’s beliefs about healing, the nurse should provide the client with the warm water and lemon juice. The nurse should not instruct the client about the benefits of lemon juice being vitamin C. The nurse should also not suggest that cold water be used instead. Asking the client to delay drinking the water and lemon juice will not support the client’s spiritual needs.
The nurse is assessing a client for spiritual distress. Which observations indicate that a client is experiencing spiritual distress?
Select all that apply.
A) The client is sitting in a chair before breakfast reading the Bible.
B) The client states he has lost his faith in God since he’s gotten ill.
C) The client is watching a religious program on the television.
D) The client is crying, pacing, and moving his head from left to right.
E) The client is overheard arguing with clergy about the existence of God.
B) The client states he has lost his faith in God since he’s gotten ill.
D) The client is crying, pacing, and moving his head from left to right.
E) The client is overheard arguing with clergy about the existence of God.
Rationale:
The client who states a loss of faith in God after getting ill, the client who is crying, pacing and moving his head from left to right, and the client who is overheard arguing with clergy about the existence of God may all be experiencing spiritual distress. The client who is observed sitting in a chair before breakfast reading the Bible or who is watching a religious program on the television is demonstrating a behavior of spiritual health.
The nursing student is reviewing communication techniques with the instructor. The nursing student is practicing assessment questions regarding spiritual or religious beliefs. Which questions would the nursing instructor identify as appropriate for the nursing student to ask when assessing spiritual beliefs?
Select all that apply.
A) “How will being sick interfere with your religious practices?”
B) “Would you like a visit from your spiritual counselor or the hospital chaplain?”
C) “Are any particular religious practices important to you?”
D) “How is your faith helpful to you?”
E) “Because you indicated you are Catholic, I suppose you fast every Friday.”
A) “How will being sick interfere with your religious practices?”
B) “Would you like a visit from your spiritual counselor or the hospital chaplain?”
C) “Are any particular religious practices important to you?”
D) “How is your faith helpful to you?”
Rationale:
This is an appropriate question for the nursing student to ask a client during an admission assessment while assessing spiritual and religious beliefs.
A client, learning that her baby has died in utero, is planning to carry the baby until natural delivery because abortion is against her religion. Which is the client demonstrating based on this data? A) Fear of retribution B) Morals C) A healthy decision D) Sound judgement
B) Morals
Rationale:
Religion and morals can at times be interrelated within health care. The client wants to maintain the baby until natural delivery occurs because having an abortion would be against her religion. The client is demonstrating her morals. The client may or may not be demonstrating sound judgment or a healthy decision. The nurse has no way of knowing if the client is in fear of retribution.
Which situation indicates a conflict in morality?
A) The nurse provides a terminally ill client a meal that includes foods that should be avoided but were requested.
B) The nurse provides the mother of a dying neonate a cup of coffee in the intensive care unit.
C) The nurse provides over-the-counter pain relievers to the daughter of a client because of a headache.
D) The nurse purchases the daily newspaper for a client who does not have any money but will when his wife comes to visit.
A) The nurse provides a terminally ill client a meal that includes foods that should be avoided but were requested.
Rationale:
Morality refers to issues that are either right or wrong. In the situations provided, the nurse who provides a terminally ill client a meal with food that he should avoid but requested would demonstrate a conflict with morality. The nurse is going against the “right” decision, which would be to not provide the client with the foods; however, the client is terminally ill and is requesting foods that he enjoys. The other situations would not involve the same question of morality.
The family of a terminally ill client requests that the client not be informed of the diagnosis. Which moral principle does the request violate? A) Justice B) Veracity C) Beneficence D) Nonmaleficence
B) Veracity
Rationale:
Veracity is the duty to tell the truth. The family of a terminally ill client is requesting that the diagnosis be withheld from the client, which would violate the principle of veracity. Beneficence is the duty to “do good.” Nonmaleficence is the duty to do no harm. Justice refers to fairness.
A client who was raped tells the nurse that she is planning to have an abortion because she cannot raise a child who was conceived this way; however, abortion is against her religion. Which action by the nurse is the most appropriate?
A) Remind the client that abortion is killing and that’s why it is against her religion
B) Ask the client what she needs to support her decision.
C) Provide information on giving up children for adoption.
D) Suggest she talk with her clergy.
B) Ask the client what she needs to support her decision.
Rationale:
The client’s decision is to have an abortion even though it is against her religion. The best thing for the nurse to do is to ask the client what she needs to support her decision. The nurse should not provide information about adoption because the client is not planning on carrying the child to term. The nurse should not suggest she talk with clergy because the client did not ask to do so. The nurse should not remind the client that abortion is killing because this would not support the client’s resolution of her moral dilemma.
A client, who received a kidney from a young victim of a car accident, states, “Life is so unfair. Why did this young person have to die so that I could receive a kidney to live!” Which observations demonstrate the client has resolved the moral dilemma?
Select all that apply.
A) The client is watching television and reading the paper.
B) The client is overheard asking the organ transplant coordinator for information on how to volunteer to help other clients.
C) The client asked the healthcare provider how many years the new kidney added to his life.
D) The client is overheard phoning a travel agent and making plans for a trip in 2 months.
E) The client is seen talking with the parents of the young victim and thanking them for their son’s gift of life.
B) The client is overheard asking the organ transplant coordinator for information on how to volunteer to help other clients.
E) The client is seen talking with the parents of the young victim and thanking them for their son’s gift of life.
Rationale:
The client needed to face the moral dilemma and resolve it before he could move on. The client talking with the parents of the victim is evidence that the moral dilemma was resolved. The client asking the organ transplant coordinator for information on how to volunteer to help other clients is evidence that the client’s moral dilemma is resolved. The other statements do not demonstrate a client experiencing a moral dilemma.
A nursing instructor is discussing moral principles with a group of students. Which comment made by a student nurse indicates the need for further instruction?
A) “A client choosing not to have a needed blood transfusion is an example of autonomy.”
B) “An example of veracity would be if a client asks her nurse if she is going to die and the nurse feels obligated to explain to the client that she is dying.”
C) “If a client asks the nurse to please come right back, and the nurse tells the client he will be back in just a couple of minutes, then that would be an example of fidelity.”
D) “A home health nurse carefully planning his or her day to assure each client gets an adequate amount of time is an example of beneficence.”
D) “A home health nurse carefully planning his or her day to assure each client gets an adequate amount of time is an example of beneficence.”
Rationale:
Justice is often referred to as fairness, which would be demonstrated by the nurse assuring that each client gets an adequate amount of time with the nurse. Beneficence refers to the fact that nurses are obligated to do good. Autonomy refers to the right to make one’s own decisions. Veracity refers to telling the truth. Fidelity means to be faithful to agreements and promises.
The nurse is admitting a client to the medical unit who was brought to the emergency department by a neighbor. The client states, “I ran out of my medication last week. I don’t have any family or close friends to help me.” Upon assessment, the nurse notes the following findings: oxygen saturation of 93% on room air, breath sounds reveal crackles bilateral bases, P 110 bpm, R 22 breaths per min, BP 110/60 mmHg. Which is the priority psychosocial nursing diagnosis for this client? A) Social Isolation B) Impaired Gas Exchange C) Noncompliance D) Interrupted Family Process
A) Social Isolation
Rationale:
Social isolation lead to the client’s current medical manifestations. The priority nursing diagnosis based on the data is Social Isolation. While Risk for Impaired Gas Exchange would also be appropriate for this client, the current data does not suggestion Impaired Gas Exchange. Noncompliance and Interrupted Family Processes are not supported by the scenario presented.
A client scheduled for surgery wants to continue to wear a religious medal. Which actions by the nurse support the client’s religious needs?
Select all that apply.
A) Keep the medal on the client but remove it once anesthesia is provided.
B) Ask the client if wearing a medal is going to ensure a successful surgery.
C) Document that the medal is being worn by the client.
D) Suggest the client not wear the medal because it will most likely be lost.
E) Explain that the medal can be safety pinned to the client’s gown.
C) Document that the medal is being worn by the client.
E) Explain that the medal can be safety pinned to the client’s gown.
Rationale:
The nurse should explain that the medal can be safety pinned to the client’s gown. This approach would ensure compliance with the client’s religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medal is being worn by the client. The nurse should not keep the medal on the client but remove it after anesthesia is provided. The nurse should not tell the client that the medal will be lost if worn or confront the client by asking if the medal is going to ensure successful surgery.
The nurse caring for a Muslim client is developing the plan of care. Which intervention would the nurse anticipate to be a priority for this client?
A) The client will be able to participate in observing Sabbath.
B) The client will be able to participate in daily prayer with a rosary.
C) The client will be able to participate in daily meditation.
D) The client will be able to participate in prayer at specific times without interruption.
D) The client will be able to participate in prayer at specific times without interruption.
Rationale:
Nurses working with Muslim clients should be aware that Muslims pray five times a day, and when developing the plan of care they should take prayer times into consideration. Muslims do not typically recognize Sabbath, pray with a rosary, or meditate.
